I I

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

F O R E V A L U A T N G C O M P R E H E N S V E 

T O B A C C O C O N T R O L P R O G R A M S

May 2005

KEY OUTCOME INDICATORS
An OUTCOME INDICATOR is a specific, 

observable, and measurable characteristic 

or change that will represent achievement 

of the outcome. 

From: United Way of America. Measuring Program Outcomes: �

A Practical Approach. Alexandria, VA: United Way of America; 1996. �

For more information, contact�

CDC Office on Smoking and Health�

770-488-5703�

For additional copies, e-mail your request to:�

tobaccoinfo@cdc.gov�

Suggested citation

Starr G, Rogers T, Schooley M, Porter S, Wiesen E, Jamison N. Key Outcome Indicators 

for Evaluating Comprehensive Tobacco Control Programs. Atlanta, GA: Centers for Disease 

Control and Prevention; 2005.

Naming of surveillance systems, databases, and evaluation tools is for example 

purposes only and does not constitute endorsement by the Centers for Disease Control 

and Prevention or the U.S. Department of Health and Human Services.
K E Y O U T C O M E I N D I C A T O R S F O R�

Evaluating Comprehensive �

Tobacco Control Programs�
Acknowledgments

We would like to extend special thanks to the following individuals 

for their assistance in preparing and reviewing this publication. 

Expert Panel Members (Appendix C)

Centers for Disease Control and Prevention (in alphabetical order):

Stephen Babb

Patrick Cox

Linda Crossett

Martha Engstrom

Reba Griffith

Corinne Husten

Kat Jackson

Jerelyn Jordan

Brian Judd

Sharon Kohout

Goldie MacDonald

Allison MacNeil

Helen McClintock

Bill Marx

Patrick Nadol 

Terry Pechacek

Linda Pederson

Lisa Petersen

Jamilyn Renna 

Robert Robinson 

Abby Rosenthal

Angela Trosclair

We also give special thanks to:

Pamela Clark

Battelle Centers for Public Health Research and Evaluation

Matthew Farrelly

Research Triangle Institute

Gary Giovino

Roswell Park Cancer Institute

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

ii
Preface�

If the United States were to meet the Healthy People 2010 goal of reducing smoking 

prevalence to 12% among adults and 16% among young people aged 14 through 17 

years, more than 7 million premature deaths after 2010 could be prevented.1,2 Studies

show that investing in state tobacco control programs and implementing effective 

tobacco control policies significantly reduces cigarette consumption and improves 

health outcomes.3–9 To continue funding state programs, however, legislators, policy 

makers, and other funders of state programs want to see evidence that the program 

is effective and that resources are being used wisely. 

To produce such evidence, state tobacco control programs must evaluate their 

programs. Good evaluation is the key to persuading policy makers that your 

program is producing results that will lead to improved health for the community. 

If good evaluation is key to proving that your program is effective, then selecting 

the right indicators to measure is key to a good evaluation. That’s where this book 

will help. 

This publication is a companion to the 2001 publication Introduction to Program 

Evaluation for Comprehensive Tobacco Control Programs, which is based on the Centers 

10,11 for Disease Control and Prevention’s (CDC’s) Framework for Program Evaluation.

In Introduction to Program Evaluation for Comprehensive Tobacco Control Programs, we 

discuss in detail the six steps of a good evaluation as they apply to tobacco prevention 

and control programs:

1. Engage stakeholders.

2. Describe the program.

3. Focus the evaluation.

4. Gather credible evidence.

5. Justify your conclusions.

6. Ensure evaluation findings are used and share lessons learned.

This new publication provides information on selecting indicators and linking 

them to outcomes, the main focus of step 3 (focus the evaluation) and step 4 

(gather credible evidence). 

In Introduction to Program Evaluation for Comprehensive Tobacco Control Programs, we 

described how to select indicators to measure program outcomes. We also gave examples of indicators and suggested sources of data on those indicators.10 This publication 

goes further. Here we discuss in detail 120 evidence-based key indicators that have 

been scientifically linked to program outcomes. We also document the evidence that 

shows the value of using these indicators to measure the progress of a state tobacco 

control program. 

P R E F A C E 

iii
To help you make informed choices about which indicators are most suitable 

for your program, we engaged a panel of experts in the field of tobacco control 

to rate each indicator on various criteria, including overall quality, resources needed, 

strength of evaluation evidence, utility, accepted practice, and face validity to policy 

makers. The ratings will help the reader decide, for example, which indicators can 

be measured within budget or which indicators are likely to carry the most weight 

with policy makers. In essence, this publication is a consumer’s guide to tobacco 

control indicators for program managers and evaluators.

In this publication we provide examples of data sources and survey questions 

that evaluators can use to gather data from their programs’ target populations. 

We were particularly careful about our choice of example data sources and survey 

questions. Most come from commonly used state and national surveys and surveillance systems, and using them will allow managers and evaluators to compare their 

findings with data from other states and over time. 

Evaluation of key indicators over time will help monitor progress toward expected 

outcomes and refine program activities as needed. Using well designed evaluation 

methods will increase your program’s and your evaluation’s chance of success. We 

encourage you to read more about the multiple purposes of program evaluation in 

10 Introduction to Program Evaluation for Comprehensive Tobacco Control Programs.

We also hope that this publication will help to advance national evaluation and 

surveillance efforts by encouraging managers and evaluators of state tobacco 

control programs to use standard questions from commonly used state or national 

surveys or surveillance systems. If states use comparable indicators, questions, and 

collection methods, we will be better able to assess the national impact of state 

tobacco control programs.

Technical Assistance

CDC is ready to help state and territorial health departments plan, implement, 

and evaluate tobacco prevention and control programs. To contact CDC’s Office 

on Smoking and Health, please call (770) 488–5703 or e-mail at tobaccoinfo@cdc.gov.

References 

1. �U.S. Department of Health and Human Services. Healthy people 2010. 2nd 

edition. With Understanding and improving health and objectives for improving 

health. 2 vols. Washington, DC: Government Printing Office; 2000.

2. �U.S. Department of Health and Human Services. The health consequences of 

smoking: a report of the Surgeon General. Atlanta, GA: Centers for Disease 

Control and Prevention; 2004.

3. �Farrelly M, Pechacek T, Chaloupka F. The impact of tobacco control program 

expenditures on aggregate cigarette sales: 1981–2000. Journal of Health Economics. 

2003;22(5):843–59.

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

iv
4. �Sargent R, Shepard R, Glantz S. Reduced incidence of admissions for myocardial 

infarction associated with public smoking ban before and after study. British 

Medical Journal. 2004 Apr 24;328(7446):977–80.

5. �Cowling DW, Kwong SL, Schlag R, Lloyd JC, Bal DG. Declines in lung cancer 

rates: California, 1988–1997. Morbidity and Mortality Weekly Report. 2000;49:1066–9.

6. �Jemal A, Cokkinides VE, Shafey O, Thun MJ. Lung cancer trends in young adults: 

an early indicator of progress in tobacco control (United States). Cancer Causes & 

Control. 2003;14(6):579–85.

7. �Barnoya J, Glantz S. Association of the California tobacco control program with 

declines in lung cancer incidence. Cancer Causes & Control. 2004;15(7):689–95.

8. �Max W, Rice DP, Sung HY, Zhang X, Miller L. The economic burden of smoking 

in California. Tobacco Control. 2004;13(3):264–7.

9. �Tauras JA, Chaloupka FJ, Farrelly MC, Giovino GA, Wakefield M, Johnston LD, 

O’Malley PM, Kloska DD, Pechacek TF. State tobacco control spending and youth 

smoking. American Journal of Public Health. 2005;95:338–44.

10. MacDonald G, Starr G, Schooley M, Yee SL, Klimowski K, Turner K. Introduction to 

program evaluation for comprehensive tobacco control programs. Atlanta, GA: Centers 

for Disease Control and Prevention; 2001.

11. Centers for Disease Control and Prevention. Framework for program evaluation 

in public health practice. Morbidity and Mortality Weekly Report. 1999;48 (RR-11):

1–40.

P R E F A C E 

v
K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

vi
Table of Contents�

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii�

How This Book Is Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix�

Chapter 1� Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 2� Goal Area 1: Preventing Initiation of Tobacco Use Among Young People . . . . . . 17 ▲ ▲

Logic Model: Preventing Initiation of Tobacco Use Among Young People. . . . . . 19�

Outcome 6: Increased Knowledge of, Improved Anti-tobacco Attitudes �

Outcome 7: Increased Anti-tobacco Policies and Programs in Schools. . . . . . . . 39�

Outcome 8: Increased Restriction and Enforcement of Restrictions on �

Outcome 9: Reduced Tobacco Industry Influences . . . . . . . . . . . . . . . . . . . . . . . . 72�

Outcome 10: Reduced Susceptibility to Experimentation with �

Outcome 11: Decreased Access to Tobacco Products . . . . . . . . . . . . . . . . . . . . . . . . 98�

. . . . . . . . . . . . . . . . . . . . . . . . . 108�

. . . . . . . . . . . 112�

. . . . . . . . 116�

Outcome 12: Increased Price of Tobacco Products

Outcome 13: Reduced Initiation of Tobacco Use by Young People

Outcome 14: Reduced Tobacco-use Prevalence Among Young People

Toward, and Increased Support for Policies to Reduce �

Youth Initiation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25�

Tobacco Sales to Minors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61�

Tobacco Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89�

Chapter 3� Goal Area 2: Eliminating Nonsmokers’ Exposure to Secondhand Smoke . . . . . 121� ▲

Logic Model: Eliminating Nonsmokers’ Exposure to Secondhand Smoke . . . . . 123�

Outcome 3: Increased Knowledge of, Improved Attitudes Toward, and �

Increased Support for the Creation and Active Enforcement 

of Tobacco-free Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127�

Outcome 4: Creation of Tobacco-free Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147�

Outcome 5: Enforcement of Tobacco-free Public Policies . . . . . . . . . . . . . . . . . . 159�

Outcome 6: Compliance with Tobacco-free Policies . . . . . . . . . . . . . . . . . . . . . . 165�

Outcome 7: Reduced Exposure to Secondhand Smoke . . . . . . . . . . . . . . . . . . . . 174�

Outcome 8: Reduced Tobacco Consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184�

Chapter 4� Goal Area 3: Promoting Quitting Among Adults and Young People . . . . . . . . . . 191 ▲

Logic Model: Promoting Quitting Among Adults and Young People . . . . . . . . 193�

Outcome 7: Establishment or Increased Use of Cessation Services . . . . . . . . . . 197�

Outcome 8: Increased Awareness, Knowledge, Intention to Quit, �

and Support for Policies That Support Cessation . . . . . . . . . . . . . . 209�

Outcome 9: Increase in the Number of Health Care Providers and �

Outcome 10: Increased Insurance Coverage for Cessation Services . . . . . . . . . . 237�

Outcome 11: Increased Number of Quit Attempts and Quit Attempts �

Outcome 12: Increased Price of Tobacco Products . . . . . . . . . . . . . . . . . . . . . . . . . 249�

. . . . . . . . . 252�

. . . . . . . . . . . 259�

Outcome 13: Increased Cessation Among Adults and Young People

Outcome 14: Reduced Tobacco-use Prevalence and Consumption

Health Care Systems Following Public Health Service (PHS) �

Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223�

Using Proven Cessation Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 242�

T A B L E O F C O N T E N T S 

vii
▲

Chapter 5 Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267�

Appendices and Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273�

Appendix A: National Tobacco Control Program . . . . . . . . . . . . . . . . . . . . . . . . . . . 275�

Appendix B: Selecting and Rating the Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . 279�

Appendix C: Expert Panel Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293�

Appendix D: Data Source Indicator Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295�

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301�

K E Y O U T C O M E I N D I C A T O R S for Evaluating Comprehensive Tobacco Control Programs

viii
General Information�

How This Book Is Organized

The chart below shows the layout of this book.

Chapter 1: Introduction How This Book Preface Is Organized

▲

▲

Purpose

Audience

▲

Using This Book to Plan 

▲

a State Tobacco Control 

The National Tobacco Program Evaluation 

▲

Control Program

▲

Logic Models

Outcome Components

Merging program planning 

and evaluation planning 

▲

for state tobacco control 

Indicators programs. Included is a 

hypothetical example.

First Three Goals of the National Tobacco Control Program

Chapter 2: Goal Area 1 Chapter 3: Goal Area 2

Eliminating Nonsmokers’ 

Smoke

Chapter 4: Goal Area 3

People

Preventing Initiation of 

Tobacco Use Among 

Young People

Exposure to Secondhand

Promoting Quitting

Among Adults and Young

Each goal area has three major sections

and terms used in 

this book

Appendices

A.

Logic Model

Depicts causal pathways 

that link outcome 

components

Indicators

outcome component in the 

logic model

Outcome Component

▲

Outcome overview: Empirical support

▲

Key indicators: Measurable 

characteristics

▲

Indicator rating table: Indicator 

ratings by criterion

▲

Indicator details

Glossary

National Tobacco Control Program Definitions of words

B. Selecting and Rating the Indicators

C. Expert Panel Members

D. Data Source Indicator Table

A list of indicators for each

Indicator profiles: 

▲

▲

▲

Additional Information

Chapter 5: Future Directions

Develop process indicators

Identify indicators to measure 

tobacco-related disparities

Encourage evaluation research

H O W T H I S B O O K I S O R G A N I Z E D 

ix